Showing posts with label patient centredness. Show all posts
Showing posts with label patient centredness. Show all posts

Sunday, July 17, 2011

How we keep score determines how the game is played


“Don’t let him in, Dad!”

I was driving my son to his soccer game when we ran into road construction.  Signs indicated that the right lane was closed ahead, so we merged into the left lane.  The very congested left lane. 

As we crawled along, a few cars zipped ahead in the right lane, which wasn’t blocked off for another 10 car lengths.  When these drivers reached the barricade, they signaled their intent to merge into the left lane.  My son’s sense of justice was offended by this “butting in line”, and he exhorted me to keep driving and prevent the right-lane bandit from merging.

To be fair to my son, his attitude has been informed by my own kvetching about drivers who don’t play by the rules.  Well, by my rules, anyway.  Why should this guy get to cut in when I’ve been stuck in this lane for all of 3 minutes?!  He can just sit there for another few minutes. 

I talked tough, but when it came down to it, I let the other driver merge.  My son was disgusted with me.

This led to a discussion about which method would get more cars through the construction zone more quickly: Option 1 - everyone merging into the left lane as soon as they saw the “Right Lane Closed Ahead” sign, or Option 2 - some drivers continuing in the right lane until it was barricaded, and then merging.  We couldn’t figure out the answer, but my son told me it didn’t really matter.  What mattered to him was how fast we got through, so he could get to soccer on time. 

Hmmm… 

I can see how he would come to that conclusion.  Getting to his game on time was the only benchmark he had.  In fact, maneuvering through the construction-zone traffic had become a game unto itself, and our goal was to get through in the shortest time possible.  Setting that goal lead to our (fantasized) tactic of blocking other drivers who wished to merge into our lane.  That tactic would get us through the line a little quicker, but at the expense of the other driver.

What if the game were played differently?  If there were evidence that Option 2 is actually more efficient, traffic engineers may want to promote it.  They could post signs asking drivers to continue in the right lane until the last moment, and then encourage courteous merging.  But, even if this option is more efficient for the driving collective, individual drivers will still “win” if they are selfish and refuse to allow anyone to merge in front of them.

Maybe we need a different way of keeping score, and a scoreboard to let drivers know how the game is going.  The engineers could set up an electronic sign that indicated how many cars per minute (CPM) are passing through the construction zone.  Perhaps every time a driver exhibited the desired merging behaviour, a happy face would flash and the CPM number would increase.  If someone blocked a merge, the opposite would happen.  I’m not sure what the most effective sign/scoreboard would be, but whatever it was, it should give this message: We’re all in this together!


Last week, I spoke with a friend who works in a chronic disease management program.  Her program had been trying to secure funding for an initiative that would engage patients in their own care, with the intent of reducing disease progression and hospital admission.  She was frustrated because the acute-care department that managed patients in hospital had received funding for a high-tech intervention that would benefit a few patients with severe disease, yet her program had been unable to obtain a fraction of that amount to promote an intervention that would keep many more people from being hospitalized in the first place.

This will be a familiar story to clinicians who see behaviour in another department affecting their own department (e.g. surgeons griping about medical specialists’ discharge patterns – see this recent post), yet feel powerless to influence that behaviour because it’s happening “outside their silo”.  Everyone is playing the game for themselves, sometimes to the detriment of the system/patient.

Healthcare organizations often use “dashboards” to show key performance indicators at various levels, e.g. mortality rates over the entire organization, consultation wait times at the department level, or complication rates for individual surgeons.  The trick is to make all these dashboard/scoreboards relevant for what really matters: the patient’s experience. 

It’s the patient’s experience that cuts across all of healthcare’s self-imposed boundaries, yet our current scorekeeping emphasizes those boundaries.  Budgets are assigned according to categories created for provider convenience – medicine vs. surgery, inpatient vs. outpatient, acute care vs. prevention.  I think that most providers, if in a conflict over behaviour or budget, would let a colleague “merge” ahead of them, if they could see that it would be better for the collective effort. 

The challenge, then, is to set up dashboards/scorecards that emphasize (and reward!) that collective effort, rather than individual success.   We're all in this together!


P.S.  If you want the answer to the “Late Merge” question that my son and I couldn’t figure out, take a look at this interesting explanation by a Minnesota traffic engineer.


Thursday, May 5, 2011

"Medical Justice" makes no sense on so many levels

Hi, I'm Dr. Visvanathan.  Please come into my office.  Before I provide you with high-quality, compassionate care, I'd like you to sign this agreement that you won't bad-mouth me publicly.

According to the American company, Medical Justice, this is how all my patient visits should start.

This story is a jaw-dropper.   Medical Justice markets itself as protector of physicians' reputations.  The problem, they say, is that anyone can anonymously blacken a physician's reputation via the internet, particularly on doctor rating sites (such as RateMDs).  The physician has limited recourse.  Medical Justice's solution is to have all a physician's patients sign an agreement that allows the physician to remove from the internet any unwanted comments the patient may post.

Doctor rating sites - and their use and misuse - aren't a new story.  Back when (now defunct) Plain Brown Wrapper was the international sensation everyone was talking about, I posted about an experiment I tried using RateMD, one of the doctor rating services.  Rather than try to shut down patient comments, I left a message on my rating page inviting comments, but challenging people to leave constructively critical comments.

My post on the site said: "Hi, it's Kishore Visvanathan here.  Thanks for leaving a comment on RateMD.  I'd like to use your comments as a way to improve the service I give.  If you have any concerns about the care I provided to you, please make a constructive comment about how I can improve."

Actually, I'm paraphrasing, because when I visited the site for the first time in a long time (prompted by writing this post), I found that my invitation for constructive criticism had been removed.  Interesting...  I wonder if they are concerned that doctors might subvert the original purpose of RateMDs, and actually turn it into a way that doctors and patients could have a dialogue about improving quality?

Other doctors have different approaches to RateMDs.  As do some medical students.

I digress.

If Medical Justice wants docs to worry about anonymous comment posting, how will "asking" patients to sign their agreement help.  Anonymous posting is... difficult to track.  I presume they're willing to make the effort to force website managers to cough up the names of the offending posters.

Most importantly, if a doctor is so worried about his/her reputation, why not earn that reputation through consistent efforts to improve service?  Sure, there will always be people who have an unhappy experience and want to gripe publicly about it.  I doubt that they would be thwarted by the Medical Justice gag agreement.

Medical Justice's legal circling-the-wagons drives a wedge between physician and patient.  We should invite feedback from our patients.  Some comments may be personal and painful to hear.  Those are the ones to pay close attention to.

Saturday, April 9, 2011

OR chatter: Let your patient be your guide

In follow-up to a recent post about paying attention in the OR, Greg Basky posted a comment about an incident in B.C.   A patient was concerned that intraoperative hockey chatter would distract the surgeon from the operation, done under local anaesthetic.  A couple of things struck me about this story.

First, this type of chatter goes on all the time.  I usually talk with men while I'm performing their vasectomy and they often comment that it helps them relax and distracts them from what's going on.  For a routine procedure, it doesn't distract me.  If I need to focus more on the procedure, I'll stop talking.  There's only the two of us in the room, so I wouldn't be having a conversation with a third person.

But, this is utterly beside the point.  It doesn't matter that I can chat without being distracted.  What matters is how the patient feels about the conversation.

I engage in the conversation just enough to get the man talking about something he's interested in: family, work - even hockey...  It's a deliberate technique to make him more relaxed.  (I've heard people suggest that, when driving a car, you're less distracted by a conversation with a passenger than you would be by talking to someone on your cellphone, even with hands-free.  I'm not sure why, but I think it's a similar situation if the surgeon is having a conversation with the patient vs. a third party.)

However, some men prefer that we not chat, and instead want to use their own method of relaxation.   That's fine with me.

Surgeons and OR staff may scoff at the idea that they could be distracted by mere conversation.  I disagree with that, but would let that point stand in the absence of evidence to the contrary.  However, we can't ignore the effect it has on patients and their perception of care.  The case reported to the B.C. College of Physicians and Surgeons is undoubtably the tip of the iceberg.

As I mentioned in the previous post, I think that casual chatter in the OR can be relaxing during a long case.  It has its place.  But, when patients are awake during procedures, we need to be aware - to the point of hyper-sensitivity - of their needs and perceptions.  (Note to the OR staff in my room: That's the reason why, when we're operating on someone using spinal anaesthetic, you might think the cat's got my tongue.  I prefer not to chat unless it's related to the operation we're doing or about to do.  You may think I'm giving you the silent treatment because I'm upset about something.  I'm not (usually).  I guess I could have explained that to you previously.  Like 20 years ago.)

The second thing that struck me was the content of different articles on this story.  Take a look at the National Post and the Leader-Post versions.  The Leader-Post (and Calgary Herald and Vancouver Sun) versions included Registrar Heidi Oetter's comments that our behaviour in the OR should be patient-centred, whether related to conversations or choice of music.  I would be interested to know why the National Post editors chose to strike those comments in their version.  Those comments are the soul of this issue.

Tuesday, March 29, 2011

Should we expand the surgical checklist to include "patient-centredness"?

Dave's comment on my last post made me think further about checklists in the OR.   In Saskatoon, we use our version of the WHO surgical checklist.  It took a while to implement, but now it is firmly part of the local culture.

The surgical checklist addresses the technical aspects of surgery - perioperative antibiotic use, anaesthetic preparation, correct side and site of surgery - but, maybe there should be a "patient-centredness" checklist as well.  It could include items that focus on the patient's experience of care.

For example:

Communication needs (language barrier, impaired hearing)
Family/friends accompanying patient - how to contact them after surgery, who will do that
Team commitment to be attentive during key parts of procedure (induction of anaesthetic, awakening, patient transfers)
Consideration for patient's feelings (avoid loud personal conversations, etc.)

This would let the OR team discuss some of these difficult behaviour/culture issues within the safer context of "what's important for the patient" rather than "what's wrong with your behaviour".

What would you add to an operating room patient-centredness checklist?

Wednesday, March 16, 2011

Should doctors charge patients who "no-show" for appointments? No.

A recent Medical Post column, “Finding Value” (March 8, p.26), caught my eye. Written by Dr. Jonathan Marcus, (bio: ... a family doctor and entrepreneur in Toronto. He writes and speaks on practice management with an emphasis on uninsured services) “How to explain no-show charges to patients” offers docs a script to encourage patients to pay for appointments they missed.

Before I share some of Dr. Marcus' tips, I want to say that it is accepted business practice in some professions (including medicine) to charge clients who don't keep their appointments. The rationale is solid: You reserved my time and have to pay for it regardless of whether or not you attended the appointment.

Having said that, I think there are 2 ways to look at no-shows. The traditional approach is that the patient is at fault and should bear the cost. Another approach is to consider how the appointment system a medical office uses may be a factor in missed appointments.

In specialty practices, long wait times for consultation mean some patients will honestly forget about their appointment. In Saskatchewan, some of our patients travel from the north and may have limited travel resources. We may have sent an appointment time that is inconvenient because of work, school, child care, etc.

In our practice, we've decided not to charge patients for missed appointments for various reasons, not the least of which is we don't want the nuisance of running a collection agency.

I think I could agree to disagree with Dr. Marcus on the relative merits of charging for no-shows. But, I'm uncomfortable when I read his suggested script for convincing patients to pay up. As I can't find a link to the article, I'll quote liberally and try to be true to the context.

In a previous article, he had offered suggestions on how office staff can collect outstanding bills. In the current article, the bill is still outstanding.

However, if your staff is unsuccessful, here's what you can do to get paid most of the time while maintaining a good doctor-patient relationship.

This is part most doctors are going to be uneasy with. We don't often have experience with the nitty-gritty business side of medical practice, and are worried that we'll affect the relationship with our patients.

During your patient's appointment, deal with his or her health concerns first, of course. Then bring up the outstanding bill.

We're off to a good start. I would be very uncomfortable with asking my patient for money before dealing with their medical problem. I think it would sour the entire visit. Also, I wouldn't want to surprise my patient with a no-show charge. I suspect that one of Dr. Marcus' previous articles suggested posting a waiting-room notice explaining the no-show policy.

Patients may give reasons for missing appointments and I recommend you waive bills for excuses such as family illness, etc. You might want to reduce rather than waive fees if the patient has financial difficulties. Paying a few dollars keeps patients accountable and reduces future no-shows, while respecting their financial situation.

Now I'm in the judge and jury. I have to decide if their story is worthy of a break. (In the case of a family illness, would my patient have to bring a doctor's note? To a doctor?) How will I judge their degree of financial hardship?

It’s important that you discuss outstanding charges in a nonjudgmental, relaxed manner. The first thing I say to patients is, “I’ve been your doctor for (however many) years. I love our doctor-patient relationship and hate to have to charge you for this.”

Is this a mixed message? I love our relationship, but I’m going to charge you for missing an appointment.

I may add, “This fee is not a punishment. It just covers the cost of running my practice.”…

…By this point, most patients have agreed to pay.

Some patients may still hold out. When this happens, I remind them I usually see patients on time for their appointments and I’m able to do so because I don’t double-book. The flip side is that I expect them to respect my time by paying for appointments they miss.

Dr. Marcus runs his clinic on time, but what about the other doctors to whom he is offering advice. If they don’t run on time, and/or double-book, are they still entitled to bill for no-shows? The real “flip side” is allowing patients to submit an invoice for the time they spend in the waiting room beyond their scheduled appointment.

At this point the situation is usually resolved. Rarely, patients continue to protest. If they do, I then say, “Someone has to be responsible for the missed appointment and there are only two people in the room – you and me. Who should it be?” It’s incredibly difficult for a patient to look you in the eye and decline to accept financial responsibility when you say this.

I mentally role-played saying this line to a patient, and it made me cringe. If a patient couldn’t look me in the eye because of something I said, I would be ashamed of myself. I have all the power in the relationship. Surely my patient would be concerned that their care may suffer if they don’t whip out their wallet, pronto.

What’s the next step if a patient digs in their heels and refuses to pay? The implication is that the doctor will end their relationship. (The relationship he loves…)

Having this conversation with patients reminds them of important aspects of the doctor-patient relationship: commitment, concern for patients’ well-being, reliability, timeliness and responsibility. This strengthens the relationship, decreases future no-shows, and helps you collect payment smoothly.

I’m not sure how this policy demonstrates concern for patients’ well-being, but it certainly does put the onus on them for timeliness. However, timeliness in the doctor-patient relationship cuts both ways. Patients will sometimes semi-jokingly say they feel like sending me a bill for the time I kept them waiting. If I were to charge them for missing an appointment, I bet I would actually see some similar invoices from them.

I suspect this tactic will decrease no-shows, but perhaps by driving patients away from the practice. Of course, given the difficulty people have in finding a family doctor or seeing a specialist, patients are unlikely to abandon a doctor, regardless of how they are treated. Once again, all the power is in the doctor’s hands.

If Dr. Marcus and I have such opposite views, then who’s right? We could argue, or we could collect the evidence. The evidence we look at depends on our goal.

If we implement his strategy with the intent of maximizing practice income, then we should compare the additional revenue from no-show patients with the cost of collecting that revenue. Include staff time and the even-more expensive physician time spent convincing patients to pay up. The value of the missed appointment should be discounted in the equation as the time was likely spent in some other useful activity, such as returning calls or reviewing lab results. Is there some way to calculate the value of lost goodwill?

If our goal is to reduce no-shows, then we could compare the no-show rates in two similar practices with different no-show charge policies. Comparing my Saskatoon urology practice with Dr. Marcus’ Toronto family practice is apples and oranges, but it’s interesting to note that he reports a no-show rate of 10-15%. Our clinic’s rate is the same.

It’s easy to be critical, so let me offer a suggestion for an alternate script for “no-show patients”:

I noticed that you missed your last appointment. Because your well-being is important to me, I want to find out how I can help you with appointments in the future. Is there a particular time of day that you prefer? Could my staff call you the day before the appointment as a reminder?

If you can’t make an appointment, I appreciate it if you can call as soon as possible. That will let me schedule another patient in that time, and that helps shorten our clinic’s wait time. Then, the next time you call for an appointment, I’ll be able to see you promptly.

Dr. Marcus’ advice may win the battle, but I fear it will lose the war.

Sunday, March 13, 2011

Maclean's interview with Sholom Glouberman: More on PFCC, EMR and patient experience

Here's a great interview with Sholom Glouberman, founder of the Patients' Association of Canada, is yet another illustration of how poor system design interferes with patient care.

Points of note:

He is an intelligent, confident man with extensive experience in
healthcare, yet he describes his experience as "passive".

Physicians weren't aware of key clinical information, even though it was apparently written in his chart.

Staff signatures were often illegible. His take on the possible
reason for that is interesting. I always thought it was just poor habit,
but he has reason to suggest it may be deliberate.

I particularly note one of his final points. When he is asked whether patients are being asked to participate on healthcare planning and operational committees, he says:

It’s beginning to happen. There are patients on boards of hospitals and health care organizations now. But the patients have to be trained up so that they’re not taken over by the system, and they have to have support. That’s why we need a patients’ organization that stands behind them and is a place where they can come to for resources and for help.

A mother's voice speaks loudly and clearly for EMR and PFCC

"Anonymous" left a powerful comment on a recent post "Leaders: Clear the path and your team will do their best work". As she tells the story of taking her daughter for treatment of a chronic condition, you can feel her frustration at a system that can't move a simple piece of information from one provider to another within 36 hours.

Implementing an EMR might move providers closer to patient and family-centred care, but it would certainly help patients/families overcome resistance to PFCC. A PFCC-aligned EMR would be accessible to the patient. (How could it not be?! We own our medical history!) With the same access to information as any caregiver, patients/families can choose the role they play in their own care. If you want the old "You're the doctor" approach, you can have it. If you want all your test results - explained in plain language (see this Wired magazine article for a suggestion on how this can be done) - you can have them. (Without needing to lug around a "medical binder".)

Anonymous, you speak clearly and passionately on your daughter's behalf. Your points are respectful. You don't lay blame. I can rant endlessly about the benefits of EMR, in person and on this blog, but I won't have nearly the impact that you can have. Oddly, even though power in healthcare usually rests with providers, in this case, it's the opposite. You, Anonymous, have the power to advocate for EMR. You can make the point that patient care will improve. You can tell your family's story about how your daughter's care is impeded by the lack of EMR.

Talk to the decision-makers who can make EMR happen in Saskatchewan. Tell your story to your MLA. Write to the Minister of Health and the Premier. Ask to have 5 minutes at the start of your regional health authority's board meeting to explain what an impact the lack of an EMR is having on your daughter's care. The comment you wrote is already a powerful letter-to-the-editor for your local paper. Speak to your daughter's patient support group about how EMR could make all of their lives easier.

EMR = PFCC. Spread the word, Anonymous.

Wednesday, March 9, 2011

Leaders: Clear the path and your team will do their best work

Something a healthcare senior leader said recently gave me pause for thought.

As part of a group discussion around healthcare improvement, the perennial topic of electronic medical records (EMR) came up. While everyone at the meeting agreed that EMR would be hugely beneficial to patient care, X opined that technology couldn’t change attitudes.

Here’s the context: The group had already agreed that the primary driver behind healthcare improvement should be the philosophy of patient and family-centred care (PFCC). X’s point was that having EMR would be great, but it wouldn’t convert anyone from being provider-centred to patient-centred.

I spent the next few minutes of the meeting on a thought tangent.

X’s assumption was that providers are fixed in a self-centred existence. They have to be “re-educated” and convinced to embrace PFCC. EMR and other technology don’t influence behaviour.

But, what if there’s a different explanation? Let’s assume that every nurse, doctor, clerk and housekeeper would get tremendous satisfaction from applying PFCC principles in their daily work. They may not be familiar with the formalities of PFCC, but they understand what it means to be kind and caring. Further, assume that all newly-hired providers come to their first day of work with the desire to do their best to serve their patients. What happens after that?

We beat the PFCC out of them! We put obstacles in their path, fail to reward (or even punish) sincere efforts to put patients first. We make it easier to be self-centred than patient-centred.

Here’s an EMR-related example from my practice: A man is referred to me with pain in his side, possibly related to a kidney stone. I recommend a CT scan to locate the kidney stone. He tells me that he already had a CT scan done at his local hospital. The referral letter didn’t indicate that a CT had been done, so I didn’t have the opportunity to look at it prior to this visit. I try to access the CT films using the online x-ray viewing system, but as is frequently the case when we try to do this from our office, the system is not working. I tell the man that I will check his CT the next day when I’m at the hospital and can use that system. He leaves without a definite diagnosis or treatment plan.

Another common example is the “missing” lab test. When a patient has already had a certain blood test performed, but the attending physician doesn’t have access to it (e.g. it’s a weekend and the family doctor’s office is closed), it’s just “easier” to poke the patient with another needle and repeat the test. The physician ordering the repeat test isn’t deliberately cruel; if the results were easily available (EMR!), it wouldn’t be necessary to stick the patient again, and it wouldn’t be done.

My conclusion was that X should think about healthcare providers’ behaviour differently. Rather than presuming the worst, X should assume that providers naturally want to provide PFCC, and that “the system” impedes them. If we assume the best, then our approach would change from one of trying to educate providers in PFCC, to one of trying to remove the barriers that prevent them from fulfilling their natural inclinations.

Here’s what this means for a leader: If your staff isn’t delivering PFCC, it’s not because they don’t want to. It’s because you have not created an environment that lets them do their best work.

Clear the path. Unleash the potential.

Saturday, March 5, 2011

Simplicity is its own reward

Sarah posted an interesting comment about the GP-specialist referral process:

I often wonder if simplification from the patient view can contribute to simplification from the doc's point of view.

Hmmm. Ideally, yes, but I have some reservations.

An elegantly designed system completes tasks reliably, consistently and with minimal waste. The simplicity of such a system would be evident to all users.

However, if the system is poorly designed, then not all users will “see” the simplicity. One user group may end up doing more work in order to use the system, or may suffer confusion, extra expense, and/or wasted time. Often, as healthcare tends to be provider-centred, it’s the patient who is saddled with the extra work and waste.

However, there are instances where providers will take on the extra work for the benefit of patients. This makes the process simpler for patients, but more complicated for providers. I would call this “faux-simplicity”. An example of this would be the Navigator role in healthcare.

A Navigator – often a nurse - guides patients through the complex journey of diagnosis and treatment. For example, a man who is suspected of having prostate cancer may have multiple contacts with the healthcare system including prostate biopsy, CT and bone scans, one (or more) specialty consultations, radiation treatment and surgery. It’s a huge help for the man to have the Navigator coordinate testing and travel for the man.

But, the presence of a Navigator doesn’t make the system simpler.

The patient may perceive less work and worry, but the system remains complex, and the Navigator and other providers still struggle with its waste and inefficiency. (Perhaps the perceived need for a Navigator is an admission that the system is badly broken!)

Does it matter that providers have to do more work, as long as patients are freed from the burden? Yes, it does matter. More time and resources spent wrestling with an inefficient, poorly coordinated system means less time and resources spent giving value to patients.

Ideally, a Navigator position is created as part of a broader, patient and family-centred system redesign. The Navigator would help with that improvement process and, once the system is truly simple and efficient, the Navigator should be out of a job!

An example of patient-centred simplicity that would also be simple for providers is a multidisciplinary cancer clinic. If a man were diagnosed with prostate cancer, he would visit the clinic – perhaps for several hours - where all the necessary testing and consultation would be done in one session. This would involve using Advanced Access principles to ensure same-day access to CT and bone scans. The man could see a urologist, oncologist, nurse specialist, dietician and social worker. The providers’ work is simpler because they can confer at once (with the man and his family, of course) and decide on the preferred treatment.

With current disjointed systems, each provider sees the man independently and then corresponds with other providers. This wastes the man’s time, delays treatment and is prone to miscommunication. Doctors waste more effort when they revisit the man’s chart repeatedly as each new report comes in from other consultants.

So, Sarah, I agree that simpler for the patient can mean simpler for the doctor, but it’s not necessarily so. Watch out for faux-simplicity: kludging another layer of service onto a dysfunctional process, rather than tearing it down and redesigning it so that it is truly patient-centred.

And simpler for everyone.

Monday, October 11, 2010

Joy at work

It’s not often that I have a moment of joy in the middle of a cystoscopy clinic, but I had one last week.

A cystoscopy clinic makes for a busy morning. Over the course of 4 hours, I’ll see 12 to 14 patients. Each visit involves – at minimum - an endoscopic bladder examination, discussion of the findings, and sending the results to the referring physician. It may also involve meeting a patient for the first time, asking about their medical history, arranging further testing or scheduling surgery.

I’m constantly aware of wanting to stay on schedule so as not to keep people waiting. Unfortunately, that time pressure will sometimes make me feel rushed, and that can affect my patient’s experience.

Why not schedule more time for each patient, you may ask. For some patients, rather than the standard 15 minutes, I will allot 30, especially if I anticipate that someone may require additional procedures. However, each extra time slot assigned to one patient means that another patient waits longer for their cystoscopy. And, wait times are already lengthy. It’s a difficult balance to strike.

But, during one examination last week, I found myself in the unusual situation of being ahead of schedule. Even though it was my first meeting with this patient, and I needed extra time to ask about her medical history, discuss test results (she had a tumour in her bladder) and recommend surgery, I wasn’t rushed. In the middle of that discussion, I had my moment of joy.

While explaining to the lady about what I had found, and the recommended treatment, I realized that I felt relaxed and confident. I was paying attention to her reaction to my explanation. Was she upset? Was I using medical jargon? Had she understood? Did she have any questions? I wanted to reassure her.

This was how I wanted all my consultations to go. Not only because it made me feel good about myself, but because I’m convinced that I’m a better doctor when I feel that way. I may provide the same technical results regardless of my mood (maybe…), but I think patients have a better experience when I’m relaxed.

As I thought about this, I began to wonder why I couldn’t feel this way, and offer my patients a better experience, on a regular basis. I think there are internal and external factors. Internally, I may allow myself to become flustered. That’s a habit I can work on. Externally, it comes down to an access problem. Long wait lists translate into pressure to fit in as many patients as possible in a given clinic. That increases the chance of running late, and forces me to rush, leading to an unsatisfying experience for both me and my patients. (And for any staff who may be unfortunate enough to be in the vicinity…)

So, if we work on improving our cystoscopy access problem – applying the same principles of managing capacity and demand as we have in our office practice – patients may benefit not only through shorter waits, but also through the quality of their experience. And our doctors may be more satisfied.

I think we’ve found our next access project.

And a selling point: Bring the joy!

Sunday, September 26, 2010

Loose lips

Hi, fellow health-care providers! Were your ears burning this week? They should have been, because people were talking about us.

Earlier this week, I met a man who, while not a health-care worker, is involved in a provincial health organization. Our conversation came around to a recent experience he had while one of his family members was being cared for in a local emergency department. His opinion was that there was a lack of professionalism demonstrated by the staff – physicians and nurses – in that ER. He had no complaints about the care provided to his relative. What troubled him was the seeming lack of concern for patient privacy and confidentiality.

He said it was impossible to ignore loud discussions that included details of other patient’s medical history and treatment, as well as staff’s “editorial comments” of their impressions about a patient’s demeanor. Some whispered comments were followed by laughter, which he admitted could have been innocent, but naturally made him wonder if some patients were being ridiculed.

His family member was admitted to hospital where he observed similar incidents on the ward. He was particularly annoyed that he regularly heard staff discussing their social lives at length, presumably while “on the clock”.

His final comments were that he was reluctant to raise his concerns with staff because he worried that it might have repercussions for his relative’s care, and also that he wondered who was responsible for overseeing appropriate staff behaviour.

Ouch! The truth hurts.

I’ve been guilty of these lapses, and see them regularly in the ER, hospital wards and other patient care areas. But, my first impulse was to explain to this man – who didn’t work in health-care – why this behaviour is sometimes unavoidable.

First of all, certain patient care areas – especially ERs, recovery rooms and critical care areas – bring together multiple patients, their families and medical staff in a confined space. Because staff needs to closely monitor the patients’ conditions, it’s not always possible to step away to a more private area to discuss care. Also, in order to be efficient, it’s sometimes more convenient for staff to have conversations about patients in the hallway outside a ward room, rather than searching for a more private spot.

However, I didn’t offer these reasons to the man, because my heart wasn’t in it. I knew they were more excuse than reason. We can do better. This experience had obviously affected his confidence in health-care providers, and empty explanations would only compound the problem.

Later in the week, I attended a meeting of our health region’s Patient and Family Centred Care advisory council. We heard a presentation about a proposed change in the ERs with the implementation of an electronic “white board”. Many ERs use a white board to keep track of patient status, pending tests, tentative diagnosis and consultations requested. While intended for staff use, they are often posted in very visible locations that anyone can see. As we move toward using a district-wide electronic medical record, these white boards will be replaced with large computer monitors that display the most current information about each ER patient. For example, if blood test results are ready, an alert would be displayed, letting staff know immediately that results can be reviewed. At present, staff need to remember to check intermittently to see if results are back, and this delays the next step in diagnosis and treatment.

While current (and proposed electronic versions) white boards don’t display patient names, that’s small comfort. Bed numbers are shown, so it’s easy to match the patient to the diagnosis. We rely on the anonymity granted by being a large urban centre, and the fact that it’s unlikely that ER visitors will know anyone who is currently being treated. But, what about smaller towns? And, good luck to you if you are a health-care worker being treated in the ER of your own workplace.

Imagine this scenario: You’re a consultant called down to the ER to see a patient. As you walk in, you see a colleague lying on a stretcher. As you walk by the white board, are you going to take a quick peek at his bed number to see what’s going on? Even if there isn’t a diagnosis given, you can see what tests are pending, and which medical service has been consulted. Cardiology? Uh-oh, probably a heart attack. Psychiatry? Hmm, interesting. Are you going to take a peek? No? C’mon, really?

The electronic white boards would not identify patients and, as was explained to us, the symbols on them would be somewhat cryptic so as to foil easy interpretation by unauthorized viewers. Well, short of using Klingon, I’m not sure we’ll have much success in disguising the symbols’ meaning. In any case, we don’t want staff to be confused as to their meaning as that would defeat the purpose of displaying them in the first place.

As one of the council’s community members pointed out, families might actually find white boards useful as a way to monitor their relative’s status and progress in the ER. In order to do that, they would need to understand the information and would naturally ask medical staff what it all meant, thus exposing the status of all ER patients.

Several community members commented that they would accept the display of patient information if it would improve the efficiency in the ER. Hearing that comment made me realize that we (health-care workers) are framing discussion about privacy issues in a way that makes patients and families feel that they are obliged to accept violation of their privacy in return for efficient and high-quality care. The impression that our community representatives had (because that’s the impression we gave them) was that, if we don’t prominently display private patient information, an ER can’t function properly. Take it or leave it. And, of course, when put like that, they’ll take it.

But, it’s a false dichotomy. There are more than 2 choices here. The beauty of digital information is that up-to-date data can populate many different devices simultaneously. We don’t need a Jumbotron blurting out patient status. Instead, display it on desktop monitors and iPhones. That’s my quick take on how to address the problem – someone else has likely solved it more elegantly. My point is that we shouldn’t ask patients to give up an important aspect of their care because it will be simpler (for us) to maintain the status quo. As another community representative put it, patients shouldn’t have to “settle”.

Now, back to the first gentleman’s observations about medical staff’s behaviour. He didn’t confront anyone at the time because he didn’t want his relative’s care to be affected. He also mentioned that he thought it wouldn’t make any difference even if he did raise it with the offenders. His rationale was that if people were far enough out of touch with appropriate professional behaviour that they were compromising privacy, they probably had a mindset that would not react well to criticism. Our system forced him to “settle”.

I asked him how he would fix the problem. He suggested that senior staff should be setting an example, by insisting that conversations take place in private locations, or at least by keeping voices low and being aware of who is within earshot.

Great idea, but not so easy to do. This behaviour is so much a part of our local culture that I think even senior staff would hesitate to be perceived as being critical of colleagues’ behaviour and labeled as “oversensitive”.

Maybe having staff hear about privacy concerns in patients’ and families’ own words would have an effect, in the same way this gentleman’s story had an effect on me. We could solicit feedback from clients regarding their impression of how their privacy was respected while they received medical care. Two or three questions would probably do it. This wouldn’t be a secret undertaking. On the contrary, we would inform staff that the survey was going on, and that they would see the results.

And, of course, we would post the results for the public to see. On the white board.

Monday, February 1, 2010

Semi-transparent

I’ve been feeling guilty since my last post. I hadn’t shown you our 3rd NAA/wait time chart for many months, and if you’ve been following our adventures, you know that the 3rd NAA was the raison d’ĂȘtre of this project. When I finally posted the recent data, it was in anticipation of our upcoming backlog blitz that should drop the 3rd NAA to our target level of 2 weeks.

Our Advanced Access project has broadened to a Clinical Practice Redesign effort, and so has a wider range of goings-on to share in this blog. However, I’m aware that I’ve used that wealth of material as an excuse to avoid exposing our biggest failure: we have not beaten the backlog, and our patients continue to wait too long for their consultations.

I rationalized it beautifully in the last post, didn’t I? I pointed out that the number of FTE urologists in Saskatchewan had dropped over the last few years, and that we were lucky the wait times hadn’t soared as a result of the manpower situation. And, I sweetened the bitterness of showing a stagnant 3rd NAA trend by breaking the exciting news of the backlog blitz.

Why did I keep this under wraps for so long? Here are a few reasons:

As the project lead, I find it frustrating and embarrassing to admit that, while we’ve had success in other areas (there’s that rationalization again!), the main goal eludes us.

When I share our results at meetings and with colleagues, I feel it undermines my credibility as a “champion” for this type of quality improvement.

Other physicians may be reluctant to start similar projects if they see early adopters are struggling to achieve durable results.

Blog posts about an unchanging 3rd NAA would be pretty dry. (Lame reason, I admit.)

I have no malicious intent, and I have never knowingly posted misleading data. However, I recognize that withheld information can affect decisions, impressions and outcomes as much as incorrect information can.

In this case, our Clinical Practice Redesign project continues because we’re excited about the positive changes that we see coming from it. The 3rd NAA data is simply a way we measure our progress and consider other improvements that we can make. As such, apart from the reasons noted above, there’s little risk in sharing the data (flattering or not) with you.

But that’s the case in our group; what if the situation were different? What if we were part of a “pay-for-performance” compensation plan, where our remuneration was dependent on providing prompt consultation? Or, if there were another urology group in town, there would be competition for referrals, and a shorter wait time would be a potent marketing tool.

Most importantly, what does a lack of transparency mean for patients? If all else (demeanor, aptitude and location) were equal, people would likely choose the specialist with the shortest wait time. Perhaps wait time would be the prime criterion for some to make their choice. Controlling access to the information then takes on a new importance.

So who controls the access? Ontario and Alberta share some of their acute care wait times online. Information about wait times to see Saskatchewan surgeons is already collated in an online database and available to referring physicians. They could (and are intended to!) share this information with their patients, to assist in making an informed decision about a specialist referral. The information, therefore, is not considered a secret yet, at present, it is password-protected.

If a patient wished to obtain wait time information, she could do so without relying on a physician to grant her access to the database. The information is available, but not without doing a lot of work. She would call all the offices of that particular specialty and ask what the wait time would be for a new referral appointment. (This is essentially the same process used to fill the database, i.e. self-reported wait time.) If she required a sub-specialty consultation (such as a shoulder problem, rather than a knee problem), she would also ask if that surgeon dealt with that area – also information contained in the database.

So why would we make our patients jump through hoops to gain access to information that we already have, and that they can laboriously obtain of their own accord? (Could anyone make a case that they have a right to the information?) There are good reasons why we might restrict access. We want to be sure that the self-reported data is accurate. After all, if livelihoods may be affected by this information, even the most earnest professional may be tempted to fudge the figures slightly.

But, surely the information physician’s clinics would report to the database would be the same as they would give our to our fictional, diligent patient over the phone. If so, she’s no worse off. I suspect that information reported by physicians to the Department of Health would be at least as accurate as that given out ad hoc to curious patients, as physicians would realize that there would be some auditing/confirmation process applied eventually.

If I have been reluctant to share our wait time data for reasons that bear trivial consequences for me, how will people behave when the stakes are higher? What expectations and rights do patients have about access to information that is critical in their informed decision-making around their healthcare?

Monday, October 19, 2009

A Thousand Cuts

Initiatives to reduce wait times for surgery generally focus on the interval from when the surgeon submits a booking to when the surgery is completed. It's hard to imagine a less client-centred measurement.

The time from booking to surgery describes the system’s awareness of the client's need. But, that person has been aware of their need since the onset of symptoms, or the finding of an abnormal lab or x-ray result by their primary care practitioner. A common example of this in urologic practice is the man who has an abnormal PSA (prostate-specific antigen) blood test during his annual medical review. This triggers a series of other events (read: waits) that may culminate in the diagnosis and treatment of prostate cancer.

The series of events looks like this:
  1. PSA blood test
  2. Consultation with Urologist
  3. Prostate biopsy
  4. Definitive treatment (radiation or surgery), if cancer is diagnosed
That's a pretty high-level view of the man's journey through the system. Of course, I mean that's how the system usually looks at the process. The man may see it like this: